HomeMy WebLinkAboutwai2025-00023 - WAI Health Waiver - 4/3/2025 MASON COUNTY
COMMUNITY SERVICES
Building Planning Environmental Health,Community Health
415 N 6i'Street, Bldg 8, Shelton WA 98584,
Shelton:(360)427-9670 ext 400 4i Belfair: (360)275-4467 ext 400 4 Elms: (360)482-5269 ext 400
FAX (360)427-7787
Application for Waiver/ peal
Amount Paid:
Receipt Number: ��
Instructions �n I ,NI '�"�_ wnuz
1. Complete Parts 1 and 2. No determination can be made unfit these parts are fully completed.
2. Fees may be billed for waivers and appeals, based on the Environmental Health Fee Schedule.
3. Submit completed application with attachments to Mason County Public Health for review.
PART 1. Applicant/Parcel Identification
Name of Applicant Kevin Klein -Go Feasibility Telephone 206-219-0665
Mailing Address of Applicant P.O. Box 1176
City Sumner State WA Zip 98390
12-digit Tax Parcel No. 1 2 2 1 6 -- 7 5 -- 9 0 0 3 2
Site Address 51 E Pendragon DR, Belfair,WA 98528
Subdivision Name and Lot SP#2107-Lot#2
PART 2: Nature of Waiver/Appeal
❑ Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists)
❑ Separation ❑ Food Sanitation Requirements
❑ Building Permit Review Policies ❑ Group B Water System Regulations
❑ Location,WAC 246-272A-0210 ❑ Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines
❑ Mason County Onsite Standards ❑� Departmental Determinations
�' Other
Description of Waiver/Appeal(include justification, additional material may be attached.):
Applying for a local waiver to reduce the setback from the primary drainfletd to the
property line down to 2 ft.This is necessary due to site conditions and to maintain
"nathaoliu,to hajolelings, istruictumas8 drainage In line with the rey nt th petty
line is 11paradmant of the draingeld
Applicant Signature: Date: 4.2-25
1:\EH Forman Waiver-Appeal Mason County Local Revised 1/202017
Page 1 of2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
❑Appeal YVaiver ❑ None required n Class A ❑ Class B ❑ Class C
2. Identification of Specific Code/Standard/ Determination (include date of determination or latest Code/
Standard revision) spy Z-�.Z}F�0-? C�
3. Nature of Appeal: l�
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4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board Public Health Director
❑ Certified Contractor Review Board Environmental Health Manager
5. Mitigating Factors:
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6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submitted. , �,,,, n C�Y�
Staff Signature: `/L�cr�J�✓'" • V' " Date:
PART 4: Determination of the Hearing Official
The hearing official has determined that approval of this request will not adversely affect public health and
is hereby granted. This decision is based on the following findings and conditions:
❑ The hearing official has determined that approval of this request could potentially adversely effect public
health and is hereby denied.This decision is based on the following findings and conditions:
Hearing Official Signature: 5x Date: .T 2J
7:\EH Forns\Waiver-Appeal Mason County Loral Revised 120/2017
Page 2 of 2
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